Download ocular trauma

Orbital Trauma
Grant S Lipman MD
Wilderness Medicine Fellow
Clinical Instructor, Division of Emergency Medicine
Stanford University School of Medicine
Case Presentation
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12 hrs s/p blepharoplasty – c/c: bleeding eyelid.
“I’ll only see a plastic surgeon.”
PE- venous blood from incision
VSS, eye grossly normal
VA – 20/20 bilaterally , PERL
Plastics: “What kind of insurance does he have? Cash? I’ll
be down.”
3- 4 hours later- repeat PE:
VSS, right eye dilates to light.
Orbital Architecture
Approach to eye examination
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ULTIMATE GOAL
Systematic Exam
VA – vital signs
EOM/Sensation
Slit lamp exam
Fundus
Referral
Corneal Abrasions – Presentation
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Symptoms
Signs
Corneal
Abrasions
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VA test
Remove contacts
Slit-lamp exam
Corneal Abrasions
Corneal Abrasions
Corneal Abrasions - Management
• To patch or not to patch, that is the question.
• Flynn et al: J. Family Practice. 1998.
• Le Sage N et al:Ann of EM. 2001.
• Contact lens wearer
• Non-contact lens wearer
• Topical anesthetics
• Ophthalmology consult?
• Follow- up: 48 hrs
Subconjunctival Hemorrhages
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Definition
Symptoms
Signs
Complete exam
Treatment
Iritis- Presentation
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Definition
Symptoms
• Photophobia
• Eye pain
Signs
• Limbus injection
• Miosis
• Mydriasis
• VA
Anterior Chamber Reaction
Hypopyon
Iritis – Management
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Complete Examination.
Cycloplegic
NSAIDS
Sunglasses
No antibiotics
Topical steroids?
Follow-Up
Hyphema- Presentation
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Definition
Symptoms
Grading
• 0 RBC’s
• I <1/3
• II 1/3 – 1/2
• III > 1/2
• IV eight ball
Hyphema- Management
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Ophthalmic consult
Pupillary play/Eye Patch
Reverse Trendelenburg
Anesthesia /Anti-emetic
IOP control > 30 mmHg (>24 mmHg in HbSS)
Admission
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HbSS
Anti-coagulated
> Grade I
Decreasing VA
ED evaluation > 1 day after initial injury.
Complications
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Re-bleed
Post-traumatic glaucoma
Lens subluxation
and dislocation
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Definition
Disposition
• Subluxed
• Dislocated
Post-traumatic Cataract
Retinal Detachment /Vitreous
Hemorrhage
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Definition
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Symptoms
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Photopsia
Image distortion
Painless
Floaters
Floaters with flashing light
Defects in VA
Vitreous Hemorrhage
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VA/Red reflex/RAPD
Fundoscopy
Ophthalmology consult
Disposition
Retinal Detachment
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RAPD/VA
Fundoscopy
Shafer Sign
Ophthalmology consult
Disposition
Retrobulbar Hemorrhage Presentation
• Definition
• Symptoms
• Critical signs
• Proptosis
• Visual acuity
• Marcus-Gunn pupil
• Red desaturation
Retrobulbar HemorrhageManagement
• “TIME IS RETINA”
• Progressive
• Lateral canthotomy
• CT scan of orbit
• Disposition
Blowout Fracture- Presentation
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Definition
Symptoms
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Critical signs
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Pain
Double vision
Numbness to cheek
tenderness
Restricted EOM
Subcutaneous emphysema
Globe displacement
Globe trauma
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32%
Blowout Fracture - Etiology
Theories
Waterhouse 1999
• Buckling
• Hydraulic
• Fracture site
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Inferior wall
Medial wall
Superior rim
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CNS injury
CSF leak
Intracranial
- bleed
Blowout Fracture- X-ray
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Screening
Teardrop sign
Blowout Fracture- CT
• Clinical indications
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Depressed eye
Nerve anesthesia
EOM entrapment
Orbital roof
• Coronal and axial cuts
Blowout fracture- Management
• Consults
• Nasal Decongestants
• Antibiotics
• Evidence?
• Sneezing/Blowing Nose
• Disposition
• With entrapment
• Without entrapment
• Associated injuries
Ruptured Globe –
Presentation
Incidence
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1.1-3.5%
Symptoms
Predictive signs
1) VA showing light
perception or worse.
2) Abnormal deep/shallow
anterior chamber.
3) Opacity preventing view
of fundus.
4) IOP of 5 or less.
Ruptured Globe - Management
• Diagnosis Suspected – STOP Examination
• Do NOT put pressure on globe
• RSI
• Br. J of Anesth 1999
• Antibiotics
• Tetanus
• Antiemetic
• CT scan
• Prepare for surgery.
Take home points
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Systematic approach to eye exam
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Visual acuity = vital signs of the eye.
Goal – protect the globe
Complete ocular examination
Corneal Abrasions: antibiotics, do not patch
Subconjunctival hemorrhages – painless
Iritis – cycloplegics and sunglasses
Hyphema- Ophthalmology, patch, IOP.
Lens – subluxed vs. dislocated
Posterior segment – floaters/ flashing lights = Ophtho
Retrobulbar hemorrhage – loss of VA, pain, proptosis.
time is retina
Blowout fracture – Waters view, CT for entrapment.
Globe rupture – Ophthalmology, patch.
Case Presentation
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Patient to OR for a stat lateral canthotomy.
S/p operation, VA is 200/45 in right eye.
Retrobulbar hemorrhage is a 1 in 15,000 side effect of
blepharoplasty.
REFERENCES
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Cullom, R. Douglas J (ed) et al. The Willis Eye Manual, Office and
Emergency Room Diagnosis and Treatment of Eye Disease. J. B.
Lippincott and Co. 1994 pp. pp. 19-48.
Effect Of Rocuronium Compared With Succinycholine On IOP During
RSI. British Journal of Anesthesiology. 1999 May; 82 (5): 757-60.
Ferrera, Peter C (ed) et al. Trauma Management, An Emergency
Medicine Approach. Mosby Inc, 2001: 201-215.
Flyn CA, D Amico F, Smith G. Should We Patch Corneal Abrasions?
Meta Analysis. Journal of Family Practice. 1998; (47): 264-70.
Le Sage N, Verrenult R, Rochette L. Efficacy of Eye Patching for
Traumatic Corneal Abrasions: Controlled Clinical Trial. Annals of
Emergency Medicine. 2001 Aug; 38 (2): 129-34.
Roberts, James R, Hedges, Jerris R (ed). Clinical Procedures in
Emergency Medicine. W.B. Saunders Co. 1998: 1116
Tintinalli, Judith E (ed) et al. Emergency Medicine, A Comprehensive
Study Guide. McGraw Hill, 2000: 1501-1506.
Waterhouse N, Lyne J et al. Investigation Into Mechanism Of Orbital
Blowout Fractures. British Journal of Plastic Surgery. 1999 Dec; 52 (8):
607-12.